|Year : 2016 | Volume
| Issue : 1 | Page : 1-2
The persistent problem of diagnostic errors
Dauda Eneyamire Suleiman
Department of Pathology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
|Date of Web Publication||6-Sep-2016|
Dauda Eneyamire Suleiman
Department of Pathology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Suleiman DE. The persistent problem of diagnostic errors. Ann Nigerian Med 2016;10:1-2
In the year 2000, the Institute of Medicine Committee on Quality of Health Care in America published a report titled: To err is human: Building a safer health system. The report brought patients' safety issues to medical and public attention and highlighted the gross under-reporting of medical errors, especially diagnostic errors. Diagnostic errors may be defined as “any mistake or failure in the diagnostic process leading to a misdiagnosis, a missed diagnosis, or a delayed diagnosis.”
Diagnostic errors in medicine occur frequently but are usually under- or un-reported; its contribution to patient safety being largely de-emphasized. The truth though is that the study of medical diagnostic errors is a most challenging feat as it is very difficult to detect and analyze. In a 2013 report by Graber, various research approaches to determining the incidence of medical errors were enumerated. These include autopsy reviews, standardized patients, second reviews, diagnostic testing audits, patient and provider surveys, malpractice claims, case reviews, and voluntary reports. A wide range of studies using some or a combination of the aforementioned approaches have revealed that a breakdown in the diagnostic chain result in a significant number of patient death and increased morbidity. Certain studies on malpractice claims have revealed that diagnosis errors far outnumber medication errors as a cause of lodged claims. Autopsy reviews have found the rates of major missed diagnosis to be rather wide with values of 4.1% and 49.8% being quoted. Diagnosis errors are not only the most common medical errors, but they also represent the most dangerous of medical mistakes.,
Review of literature generally reveals an incidence of diagnostic errors to be in the range of 10–15%. In the US, 40,500 adult patients die annually with Intensive Care Unit misdiagnosis. The same study also showed that 5% of the US adults experience diagnostic error annually in outpatient settings. In addition, over 50% of pediatricians in a survey reported that they made a diagnostic error at least once or twice per month; almost one-half reported diagnostic errors that harmed patients at least once or twice per year. It is difficult to determine the exact cost of diagnostic errors, but it is easy to imagine that it could lead to unnecessary hospital visits, wrong treatments, unnecessary procedures, readmissions, and general health deterioration.
The reasons for diagnostic errors are varied and include the increasing loss of clinical skills by physicians accompanied by the over-reliance on technology for diagnosis, the overconfidence of clinicians on their diagnostic abilities allied with the lack of feedback process to physicians on their diagnostic performance, the dearth of explicit curricula on clinical reasoning, and the lack of a total quality management system in medical laboratories among others. As far as testing-related diagnostic errors are concerned, Epner et al. enumerated five taxonomical causes of errors, namely:
- An inappropriate test is ordered
- An appropriate test is not ordered
- An appropriate test result is misapplied
- An appropriate test is ordered but a delay occurs somewhere in the testing process and lastly
- The report of an appropriately ordered test is inaccurate.
More important perhaps is the fact that when these errors occur, they are either not detected or deliberately overlooked. Herein lies the crux of the problem: If these errors are not reported and the appropriate steps are not taken to forestall future occurrences, it creates a huge pile of misdiagnosis or missed diagnosis that is inevitably swept under the carpet leaving the patient to bear the brunt of these errors. It casts serious doubts on our purported morbidity and mortality statistics and raises serious questions about the quality of (especially tertiary) medical care that we offer our teeming patients. In this regard, the sad decline of the hospital autopsy is unfortunate as its audit role is well documented.
In curbing these trends, a holistic approach to the problem is required. It is important that clear operational definitions of diagnostic errors are made by relevant regulatory bodies. Furthermore, certain questions need to be answered: What level of diagnostic errors should be considered “acceptable” without compromising patients' safety significantly? Is it possible for a diagnosis to be wrong without a diagnostic error? What should be done when a diagnostic error is reported or inadvertently discovered? In addition, measures must be taken to improve clinical autopsy rates so that a veritable audit tool is not lost. There should be standardized protocols for reporting and reading radiological and laboratory investigations. All clinical laboratories must institute quality management systems in all laboratory diagnostic processes to improve confidence and increase the reliability of their results/reports; clinical laboratories must have access to clinical pathologists to ensure that laboratory results are interpreted in the right clinical contexts. Moreover, the cognitive reasoning must be deliberately captured in the curricula for undergraduate and postgraduate medical trainings. In a collaborative team, individual roles must be well defined, and the team dynamics need to be clearly spelled out. There should also be practical strategies to monitor performance and measure incidence of errors when they occur.
Systematic implementation of the above “change” ideas would go a long way in ensuring that the oft-quoted medical maxim “primum non nocere” is realized.
| References|| |
Plebani M. Diagnostic errors and laboratory medicine – Causes and strategies. Electron J Int Fed Clin Chem 2015;26:7-14.
Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf 2013;22 Suppl 2:ii21-7.
Schiff GD, Kim S, Abrams R, Cosby K, Lambert B, Elstein AS, et al
. Diagnosing diagnosis errors: Lessons from a multi-institutional collaborative project. Adv Patient Saf 2005;2:255-78.
Epner PL, Gans JE, Graber ML. When diagnostic testing leads to harm: A new outcomes-based approach for laboratory medicine. BMJ Qual Saf 2013;22 Suppl 2:ii6-10.